Is it time for the diaphragm to make a comeback?

Last month, university student Priya wrote an article for the student newspaper about her experience of severe depression on the pill. The response was overwhelming: not only was the article shared over 140 times, but many of Priya’s peers approached her with stories of the same, or similar, experiences.

In spite of her trauma, Priya made the decision to stay on an alternative brand of contraceptive pill. “To be honest,” she says, “I was in a long-term relationship and didn’t want to have sex with condoms.” If her mental health might improve on another pill, one can imagine why: condoms have a higher rate of typical use failure than the pill, and many couples prefer sensation without the latex barrier.

This trade-off, between our mental health and our sex lives, between discomfort and convenience, is the core work of many women’s experimentation with their contraception options. Indeed, a 2016 Dutch study of over a million women found hormonal contraception to be associated with a first-time diagnosis of depression.1 But what’s left when we take synthetic hormones out of the equation?

Before the pill was available to the masses, women in the 1920s could get the diaphragm from British family planning clinics. A dome-shaped cup (similar to our diaphragm muscle) that covers the top of the cervix, the diaphragm blocks sperm from accessing eggs that are ready to be fertilised. Spermicide is placed on the cup before use.

This non-hormonal contraceptive method is found to have a similar failure rate to male condoms — 12% and 18% respectively, for typical use2 — without the same impact on sensation. So why hasn’t the diaphragm stood the test of time?

Dr Caroline Rusterholtz, a research fellow at Cambridge University studying the history of youth sexuality, said that it was primarily women’s disgust at their own genitals that prevented a higher uptake of this method. As well as poor hygienic conditions in the 1930s-1950s making it difficult for women to properly wash their diaphragms, clinicians found that women were having trouble inserting the device, as “for some of them it was their first time touching their own vagina.”

“I think, in our very sexist society, there’s always been distaste about ‘mess’ and bodily fluids associated with women, and not surprisingly, a lot of women internalised that feeling”

The commercialisation of the pill in 1961 didn’t entirely wipe out use of diaphragm, as the rise of the second wave feminist movement in the 1970s brought its own spate of criticisms against high doses of hormones in the contemporary birth control pills. While feminist campaigns were successful at lowering the dangerous amount of oestrogen in these pills,3 they weren’t able to completely eradicate taboos around female genitalia.

Public perception of diaphragm users in the 1980s drew strongly from negative ‘feminist’ stereotypes of the time. Sheila, from Edinburgh, who used the diaphragm during this era, said women like her were seen as “women who didn’t shave their legs… and might have used a menstrual sponge instead of a Tampax!”

“I think, in our very sexist society, there’s always been distaste about ‘mess’ and bodily fluids associated with women, and not surprisingly, a lot of women internalised that feeling,” she said. “Books like Our Bodies Ourselves were very much read at universities, but were not very mainstream, so that reinforced the association with ‘lefty’ feminists.”

Our Bodies Ourselves was first published by the Boston Women’s Health Collective in 1970. The authors were unphased by taboo; one of the ‘disadvantages’ of the diaphragm they list is that “Women who don’t like to touch their genitals and vagina will need to overcome this,” adding, “This isn’t difficult and worth trying to do.”

As the century rolled on, the authors’ advice fell on deaf ears. A 2015 UN report4 revealed that, in 1994, just 3% of British women and 1.8% of US women were using vaginal barrier methods, including diaphragms.

Despite its declining popularity, in the late 1990s the diaphragm appeared more than once as the punchline of jokes by male writers on sitcoms like Friends, Seinfeld and Sex and the City.5 The thought of women touching themselves was evidently a convenient comic plot device, whether most female viewers were using them or not.

Today, the canned laughter on these TV shows looks like the last cultural hurrah for the diaphragm, as in 2015, just 1% of British women were using vaginal barrier methods.6 In the US, they were practically obsolete.

Just as the diaphragm appears to be facing extinction, a similar silicone device is beginning to enter the mainstream.

For many women for whom hormonal contraception is either not an option, or comes with difficult symptoms to manage, the diaphragm is an avenue well worth exploring

The rising popularity of the menstrual cup flies in the face of any 20th century taboo around female genitalia. In 2018, searches for ‘menstrual cup’ are broadly trending up in the UK and US7, while the market for menstrual cups is predicted to witness “massive growth” by 2025.8 The cup sits lower in the vagina than the diaphragm, but both are folded and inserted manually. While one holds menstrual blood, the other holds spermicide gel.

Menstrual cups are seen an attractive option for their reusability, and those who are concerned about the environmental and financial costs of disposable sanitary products are increasingly drawn to them. The diaphragm offers these same benefits, along with all the advantages of being a non-hormonal method that women can control.

So why the cup, but not the diaphragm? Dr Joanna Bircher, a GP based in Stockport, tells me that since she started her career in 1999, only two women have requested a diaphragm from her. “As a result of this, as practitioners, everyone has become quite de-skilled,” she says, adding that if someone asked her to help fit one now, she wouldn’t feel confident doing so. For a GP, “as you become less experienced in something, you tend to only promote things you think you can offer.”

However, more recently, the diaphragm has as quietly undergone development.

The Caya, a one-size fits all model, was released in Europe in 2013, and doesn’t require a prescription. It has a unique, recessed grip that allows you took hook your finger over the rim for easy removal six hours after ejaculation, to be sure no sperm managed to swim into the cervix.

Sheila said she eventually stopped using the diaphragm because a GP told her it was the rim pressing against her bladder that was causing her recurrent cystitis. The Caya is designed to reduce the pressure exerted by older models.

According to the brand’s own data, by the end of 2017, more than 100,000 women in over 30 countries were using the Caya. Their post-marketing survey of German users in the same year revealed that the product was increasingly popular among younger women, though 41.8% were using it in combination with other methods, including withdrawal, natural family planning and ‘sympto-thermal’ methods, as used in the controversial Natural Cycles app.

It is essential to note that the diaphragm’s reliability is lower than hormonal methods, which, according to the Pearl Index, have less than 1% failure rate for typical use. But for many women for whom hormonal contraception is either not an option, or comes with difficult symptoms to manage, the diaphragm is an avenue well worth exploring.

While it may not be suitable, or even appealing, to everyone, the diaphragm gives us the chance to consider what is valuable to us in the way of contraception. At least by being fully conscious of all the options that still exist, women can get closer to discovering what is right for them.

Sophie joined The Femedic after studying Human Social and Political Sciences at university, and a brief stint working for the NHS. She’s fascinated by the ways gender has influenced medical research and practice, and by how her Catholic sex education managed to miss out so much. In her spare time, she really enjoys updating her male friends on how her period is going.